A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)
Stop the transfusion.
Obtain a prescription for a diuretic.
Place the client in high-Fowlers position.
Administer epinephrine to the client.
Administer oxygen to the client
Correct Answer : A,C,E
Stop the transfusion, place the client in high-Fowlers position, and administer oxygen to the client. The rationale for these answers is that these actions are appropriate interventions for a client who is experiencing circulatory overload, which is a potential complication of blood transfusion characterized by fluid overload in the lungs and heart failure. Stopping the transfusion will prevent further fluid accumulation, placing the client in high-Fowlers position will facilitate breathing and reduce venous return, and administering oxygen will improve oxygenation and tissue perfusion.
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Related Questions
Correct Answer is D
Explanation
A. "I will put some lubricant on the flat end of the suppository.": It is generally not necessary to use lubricant on the suppository. If lubrication is needed, it should be applied sparingly to the rounded end, not the flat end.
B. "I will lie on my left side to insert the suppository.": The recommended position for inserting a vaginal suppository is usually lying on your back with your knees bent or standing with one foot elevated, not lying on the left side.
C. “I can discontinue the medications once my symptoms are gone.": This is incorrect. It is important to complete the full course of medication to ensure the infection is fully treated, even if symptoms improve before finishing the medication.
D. "I will place the suppository as far inside my vagina as I can reach.”: This statement is correct. The suppository should be inserted high into the vagina to ensure it is placed correctly and will dissolve properly to treat the infection.
Correct Answer is B
Explanation
To prevent electrical shocks and fires, the nurse should instruct residents to disconnect electrical equipment by grasping the plug, not by pulling on the cord. The nurse should also advise residents to avoid taping electrical cords to the floor, as this can damage the insulation and create a tripping hazard. The nurse should warn residents not to use electrical equipment with exposed wires or frayed cords, and not to cover them with tape, as this can increase the risk of sparks and short circuits. The nurse should remind residents to clean electrical equipment only after disconnecting it from the power source and following the manufacturer's instructions.
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